Basic Information
| Provider Information | |||||||||
| NPI: | 1043312937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ISHERWOOD | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2350 N LAKE DR | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532114528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142987280 | ||||||||
| FaxNumber: | 4142987281 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 N LAKE DR | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532114528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142987280 | ||||||||
| FaxNumber: | 4142987281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 11/24/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1675-023 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 42866700 | 01 | WI | NETWORK HEALTH - T19 | OTHER | 42866700 | 05 | WI | MEDICAID | 42866700 | 01 | MANAGED HEALTH SERVICES | OTHER | 42866700 | 01 | WI | WPS GAMP | OTHER | 42866700 | 01 | WI | UHC-T19 | OTHER | 42866700 | 01 | WI | HIRSP | OTHER |